THE FREE HEMORRHAGES.
From any of the parts which are the source of the bleeding in hema tocele retro-uterina there may occur a rapidly fatal hemorrhage if the vessels of the part have undergone morbid change or enlargement. Many cases have been related by such competent observers as Scanzoni, Puech, Hufoland, and others, in which hemorrhages from the ovaries or the tubes have rapidly caused the patient's death; as also have varicosities of the ovarian veins. One of the rarest cases is probably that of Fritsch, where a pregnant woman bled to death so quickly from a sharply defined ulcerated spot the size of a ten-cent bit in the posterior uterine wall, that she might have had rupture of the uterus. As has been mentioned, the commonest cause of internal hemorrhage is the rupture of an extra-uterine foetal sac.
Symptoms and most of the recorded cases death oc curred within the first twelve hours; and the fact that many of them were supposed to be cases of poisoning shows that the symptoms were not so characteristic as one would suppose in a disturbance of such extent.
The physician in most cases first saw the patient senseless or entirely col lapsed, with a small, hardly perceptible pulse, and a cold, white skin. A further source of difficulty for the diagnosis is that when much blood has been effused, it spreads itself throughout the entire abdominal cavity, and so can hardly be detected.
In all cases the first symptom was pain, sometimes so violent as to make one think of the advent of a peritonitis.
Thereupon soon follow pallor of the face, frequent gaping, singultus and vomiting, a small and rapid pulse, coldness of extremities and face, in fact all the symptoms of violent postpartum hemorrhage.
Thus the diagnosis of internal hemorrhage will often be incomplete when we have not before detected the existence of perhaps an extra uterine pregnancy, or when a skilled observer has not watched the affec tion from the beginning.